Audit and Practice Survey Posters 263 – 270
263 Patient satisfaction after joint injections in primary care
Aim: Musculoskeletal pain accounts for a large proportion of people seeking help from primary care physicians. We wanted to determine the efficacy of the steroid injections when used for musculoskeletal pain.
Method: Data of 200 consecutive musculoskeletal steroid injections performed at 5 different clinics by one clinician was collected. Patients were contacted atleast a month later to ascertain the subjective effectiveness of the injection. Patients were requested to classify their response to injection into 3 categories i.e. effective, partly effective or not effective.
Impact and outcome: 188 out of 200 injections could be followed up. The site injected starting with most common was knee (45.9%), shoulder (21.2%), tennis elbow and plantar fasciitis (7.3% each), trigger finger (6.8%), first carpometacarpal joint injection (3.4%), trochanteric bursitis (2.9%), carpal tunnel syndrome (2.4%), de quervian’s tenosynovitis (1.9%) and ankle (0.9%). The effectiveness as per each site was as follows. Knee effective (65%), partly effective (19%), ineffective (16%); Shoulder effective (52%), partly effective and ineffective (24% each); tennis elbow effective (93.3%) and partly effective (6.7%); plantar fasciitis & de quervian’s tenosynovitis effective (50%), ineffective (50%); trigger finger effective (77%), ineffective (23%); first carpometacarpal injection effective (100%); trochanteric bursitis effective (67%), ineffective (33%); carpal tunnel syndrome effective (60%), partly effective (40%); ankle partly effective & ineffective (50%) each.
Discussion: The study shows that joint injections are effective in primary care settings with overall result of effective (65%), partly effective (16%) and ineffective(19%). The best results were with tennis elbow & first carpometacarpal joints. Ankle, plantar fasciitis & de quervian’s tenosynovitis had average results. The study shows that joint injections are effective in carefully selected patients and should be offered to them.
264 Audit of the assessment of the feverish child in primary care; a template for system one
Audit of the assessment of the feverish child in primary care; a template for system one.
Relevance and aims Infections are the main cause of death in children under five years and fever is one of the most common reasons for children to be brought to primary care. Assessment of children under five years with fever can be challenging for clinicians in primary care. Recent guidelines from the National Institute for Clinical Excellence (NICE) provide a clear framework for the assessment of children under five years in primary care using a traffic light system[i].
Method We completed a retrospective audit of the documentation of the assessment of children presenting with fever in an urban practice in West Yorkshire using system one records. We included all children under five years seen in a two week period with a history of fever (n=14). We assessed the documentation of colour, activity, signs of respiratory compromise , hydration status and temperature.
Outcome Results showed documentation was incomplete for all records with a variety of vital parameters omitted, notably assessment of respiratory compromise was included in just 32% of records. We designed a system one template using the NICE framework to improve documentation and act as an aid memoir for paediatric physiological parameters. A re-audit two months after implementation showed an improvement in the documentation of all parameters, in particular markers of respiratory compromise (72%).
Discussion We plan to offer the template to all practices in the Airedale training scheme to help improve assessment of fever in children under five years and subsequently re-audit across participating practices.[i] Fever in under 5’s; assessment and initial management. NICE Guidelines (CG160).
265 Utilising ‘Unplanned Admissions Registers’: an audit to review unplanned acute admissions to hospital in patients with long term conditions
Aims/Objectives This audit reviewed patients aged sixty-five and over with two or more long term conditions (LTCs) who had two or more unplanned admissions to hospital over a twelve month period. It reviewed procedures for preventing unplanned admissions and provided recommendations for change.
Relevance/Impact Currently 15 million patients in England have been diagnosed with a LTC. These people account for approximately 70% of total healthcare expenditure, due to the time and resources needed to appropriately manage them. By preventing acute unplanned hospital admissions this expenditure could possibly be reduced and patients could access more appropriate services in the community where possible.
Outcomes 75% of the patients in the audit were female, they were aged between 73 and 94 and they had on average 4.2 admissions in a 12 month period. 2/3 of the patients had a ‘trend’ apparent for their admission providing an opportunity for intervention. 1/3 of the patients received point of care treatment and were discharged, these patients ideally should have accessed alternative healthcare services rather than attending hospital.
Discussion This audit demonstrates that those already on an ‘Unplanned admissions register’ (UAR) had a lower number of admissions compared to those who were not on the UAR. This suggests that active prevention of acute admissions is beneficial and those with LTCs should be reviewed for this register where possible. Patient education about accessing services is also an important way to decrease the amount of unplanned admissions.
266 Influenza and Pertussis vaccines in pregnancy: an audit in general practice
Introduction: The seasonal influenza vaccine provides protection for both the mother and baby, therefore it should be offered to all pregnant women annually. The pertussis vaccine is offered in late pregnancy to provide the baby with protection against pertussis in early months of life, prior to childhood immunisations.
Aim: To measure the uptake of the influenza and pertussis vaccines amongst pregnant patients.
Method: An EMIS Web search for pregnant patients between 01/09/14 to 01/06/16 was conducted. The women’s age, gestation, if the influenza and pertussis vaccines were offered, accepted or declined and which healthcare professional administered the vaccine was noted.Results: 81 pregnant patients were found, of which only 39 (48.1%) were offered the influenza vaccine and 53 (65.4%) were offered the pertussis vaccine. 35 (90%) of the patients offered the influenza vaccine had been vaccinated in comparison to 50 (94%) patients being vaccinated against pertussis. 7 patients were eligible for the pertussis immunisation according to gestational age, but had not been offered the vaccine.
Conclusion: The offer rates of the 2 vaccines was low, these results were presented at a practice meeting. To improve offer rates and uptake it was agreed to increase offering pregnant patients leaflets on the immunisation and encourage all clinicians to use the pregnancy template, including these vaccinations in the template. Also, a meeting with the midwife was to be arranged to organise documenting her consultations onto the patient computer records.
267 GP Acute home visit request: an audit in general practice
Background: Currently the patients call and initially talk to a receptionist, who notes down their reason for the visit and advise they will be called back by a GP and if they do not receive a call back by 12, to ring back. Allotted time is given to the GP on call to call each patient. Aims: To review the triage system and final outcome for all patient home visit requests. Standard: 100% of patients requesting a home visit should be called back for a review on the same day.
Method: All visit requests between 01/06/15-24/05/16 were reviewed to determine the day of the week, the presenting complaint, outcome of the call and the GP who completed the visit.
Results: 100% of patients requesting a home visit were called back by the GP on call on the same day. A total of 756 requests were made during the 12 month period, of which 573 (75.8%), resulted in a home visit. Mondays (28%) were the busiest days for home visit requests with Friday (15%) the least busy. December and February had the most requests with the highest percentage conversion rates to home visits in December, 80.2% compared to an average of 56.9%.
Conclusion: The robust system has allowed the practice to meet the standard. The results were presented at a practice meeting and it was agreed during the busiest periods extra time would be allocated to the GP on call to deal with increased demand.
268 NICE-compliance of antibiotic prescribing decisions for acute sore throat presentations in urban primary care: an audit
Antimicrobial resistance poses an enormous threat, and primary care plays a crucial role in preventing this. Acute sore throat is amongst the presentations the most common and most various in aetiology. Antimicrobial resistance, diverse differential diagnoses, limited diagnostic adjuncts, and patient expectations render prescribing decisions challenging. NICE guidelines on acute sore throat management aim to ensure the best decision, both for the patient and the community.A retrospective audit was undertaken in a 9,500-patient urban practice to investigate NICE-compliance of sore throat antibiotic prescribing, to formulate interventions to increase compliance, and to assess their effects on prescribing decisions.The RCGP Sore Throat audit toolkit was used to evaluate antibiotic prescribing against NICE guidelines. The first loop was performed in February 2016 and the second loop in May 2016. Data on all sore throat presentations from the preceding 4 weeks was collected using EMIS according to 17 clinical codes. Immunocompromised patients were excluded. Based on first loop findings, we designed and implemented an EMIS sore throat proforma based on NICE guidelines, and a poster with a NICE guideline-based algorithm for consultation rooms.The interventions resulted in increased NICE-compliance of decisions for immediate antibiotics (52% vs 29.6%), delayed antibiotics (25% vs 0%), and no antibiotics (100% vs 95%), resulting in overall increased NICE-compliance of all prescribing decisions (70.5% vs 56%).Simple interventions can help increase awareness of NICE guidelines, minimising inappropriate antibiotic use while providing optimal care for patients. Further work is needed to study reasons for non-compliance and to overcome them.
269 Dermatology two week wait referrals: are we referring appropriately?
This project aims to investigate the nature of GP referrals to secondary care via the dermatology two week wait (2ww) cancer pathway at a West Berkshire GP practice (~14200 patients). Local data currently suggest a decline in the appropriateness of skin lesions being referred – referral rates are dramatically increasing whilst conversion rates decrease.The practice database was searched, spanning a 6 month period, to identify patients referred via 2ww. Referral letters were analysed, looking specifically at content, proposed diagnosis, and name of referring GP. These were compared to the outcome from secondary care consultations.In total, 75 patients were referred. The number of referrals made by individual GPs ranged from 1 to 23 (mean=5). 19 (25%) were clinically felt by dermatology to be an SCC, were suspicious of MM or were an appropriate 2ww BCC. 7 (9%) were clinically diagnosed as non-urgent BCCs, 38 were benign, 7 had no secondary care letter available and in 4 cases the lesion had resolved. At final histological diagnosis, 4 of the 75 referred lesions (5%) were SCC/MM/infiltrative BCC.GPs at this practice could improve their recognition of BCCs (9% of referred 2ww lesions were non-significant BCCs) and seborrheic keratoses (the most commonly referred benign lesion). Improvement is challenging, because unlike 2ww for other cancers, referral criteria rely broadly on physician knowledge and experience. Future research could focus on developing educational sessions for GPs, creating opportunities for GPs to shadow 2ww clinics and a telederm triage system, comparing these interventions against referral outcomes.
270 An audit of the assessment of palpitations in a tier 2 cardiology clinic in primary care
Aims/objectivesTo evaluate the assessment and diagnosis of patients referred with palpitations to a general practitioner (GP) running a tier 2 cardiology clinic in a UK general practice. Criteria and standards were set following local ‘primary care cardiology pathway’.
Content of presentation A retrospective analysis highlighted 511 patients with palpitations between April 2012 to May 2016. In total, six criteria were chosen including having an appropriate history, blood test and ECG monitoring. Standard was agreed to be 90% for each criteria. Additionally, diagnosis for each patient was also identified.
Relevance Palpitations can cause a substantial distress amongst patients. It is the second most common reason for a GP to refer a patient to a cardiologist. But less than a half of those referred will be diagnosed with an arrhythmia.
Outcomes In the clinic, from 511 patients only 5% were referred to secondary care. Interestingly, these 5% collectively met the standards for all six criteria. Whilst those not referred to secondary care collectively failed to meet the standards due to a variety of reasons. Those referred to secondary care, only 1/3 were diagnosed with a serious cardiological condition. Commonest diagnosis for remaining 2/3 was Sinus tachycardia.
Discussion Our analysis shows that a majority of patients with palpitations can be managed sufficiently in primary care. The tier 2 clinic is helping to reduce vast number of unnecessary referral to hospitals. Appointment text reminders and encouraging GPs to carry out heart monitoring prior to referral are few of our recommendations.